Practice Manager Name: (Primary contact point for ManageMyHealth to coordinate the activation)

Email:

Office Phone Number:

Mobile Number: (Mandatory)*

IT Company: (IT Company or person who provides operational support for your Medtech PMS)

IT Engineer or Contact Person:

Email:

Mobile:

Video Consultation Service - Terms and Conditions

Service Specifications and System Requirements

1. The ManageMyHealth Video Consultation Service ("Service") is subject to the ManageMyHealth Terms and Conditions, Terms of Use, Privacy Policy and Code of Conduct, which can be found online at www.managemyhealth.co.nz2. I have read and understood the service specification and system requirements for the Service which you can be found online at www.managemyhealth.co.nz3. I acknowledge the quality of video calls on the Service will be dependent on the device used and the quality of internet connection of each party on the video call. I acknowledge that ManageMyHealth Limited is not responsible or liable in any ways of any errors, interruptions or failures of the Service.

Service Pricing and how usage is charged

4. I acknowledge and accept the pricing for the Service outlined below:

a. The service consists of a monthly service fee and usage fee.

b. Due to the Coronavirus outbreak, we are waiving the $50.00 monthly service fee for all existing ManageMyHealth Patients Portal Customers until 30 Sep 2020.

c. The usage fees are billed in the units called "Video Credits" depending on the duration of the video call.

d. Video Credits can be purchased on a prepay model very similar to SMS in bundles of 100 Video Credits each for $100.00 (Excl. GST). Video Credits are non-refundable and do not expire.

e. The following special pricing is offered to support practices during the Coronavirus outbreak. Under the special pricing, Usage of services will be charged as follows and these maybe subject to change by ManageMyHealth giving 30 days, notice to us via email.

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Video Call Duration

Usage Charge

1

A short video call consult lasting up to 5 minutes

1 Video Credit

2

A standard video call consult lasting up to 15 minutes

2 Video Credits

3

An Extended video call consult lasting up to 30 minutes

4 Video Credits

4

Any video call consult longer than 30 minutes will be charged in 15 minute blocks

2 video credits per 15-minute block

Request to activate Service
5.I request and authorise ManageMyHealth Limited, to activate the service at our health care.6.I acknowledge that, we are responsible for all charges incurred for the Service provided by ManageMyHealth Limited to us.Authorisation to charge initial video credits and ongoing automatic top-ups7.I authorise and instruct ManageMyHealth Limited to: a.Invoice us for the initial video credits ("Initial Video Credits") at $100.00 plus GST. b.Automatically top-up our account with 100 Video Credits and invoice us for $100.00 plus GST, each time 80% of the pre-purchased Video credits used.8. I understand that, I can terminate the top up by giving notice in writing by emailingsupport@managemyhealth.co.nz 9.I confirm that, by submitting this form I agree to all of the above and have necessary authority to submit this activation form.